Hall, Patricia TOT N OF QUEE BU9�y
PINE DER' CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745-4.477
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Date Of CremationaL__p�
T 'me Cremation Started
Time Cremation Completed
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Type of ContainerI _ OnU C S ' �1
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
Authorization to Cremate
The undersigned requests and auttxxtzes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
crerRpte reTwins.of:
(Name) l ( )
(Street) (City) (State) Code)
who died on / / b clay of
20at 10
(place) (Address)
Name and address of nearest�lative or name of person euthortzjng cremation:
(Nam
(Ad dr )
Relador� to the deceased
Name of Funeral Horne /ter U <<
IMPORTANT:
1 represent that to the best of my knowledge,the deceased(has)6;�"
er,defibrillator ore other batt device In his or her body. (Circle One) nY e<Y operated
1 certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
Cremated remains,that any personal possessions have etcher been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demar>ds for loss or damages%ft:h may be made agairva them
by reason of or connected with the cremation of said remakes as directed,whether such claims or demands are or are not wholly
groundless.false or fraudulent.
(Witness) (Address)
(Signa a and Adddress of Relative or Legal Represen e)
Signed on this date: lot �d (�7
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains Is requested,check here
Revision:January 1,2006